national guidelines for€¦ · and mr. shogo kanamori, jica expert on medical services...

1ST EDITION OCTOBER 2010

IMPROVEMENT OF QUALITY ANDSAFETY OF HEALTHCARE INSTITUTIONS

NATIONAL GUIDELINES FOR

(FOR TRAINING INSTITUTIONS)

MINISTRY OF HEALTHDEMOCRATIC SOCIALIST REPUBLIC OF SRI LANKA

Quality Series 6

Quality Series No.6

National Guidelines for Improvement of Quality and Safety of Healthcare Institutions

(For Training Institutions)

First Edition

Editors: Dr. Wimal Jayantha

Deputy Director General/Planning, Ministry of Health

Dr. S. Sridharan

Director Organization Development, Ministry of Health

Dr. C.J. Aluthweera

Coordinator for National Quality Assurance Programme, Ministry of Health

Mr. Shogo Kanamori

JICA Expert on Medical Services Administration

October 2010

COPYRIGHT © Management Development & Planning Unit Ministry of Health 385 Baddegama Wimalawansa Thero Mawatha., Colombo 10, Sri Lanka October 2010 National Library of Sri Lanka Cataloguing in Publication Data Quality Series No.6 National Guidelines for Improvement of Quality and Safety of Healthcare Institutions (for Training Institutions) ISBN: 978-955-0505-09-8 Printed in Sri Lanka This Publication is sponsored by: Japan International Cooperation Agency (JICA)

Preface

Sri Lanka has reached a high level of health status amongst its population in comparison with the countries in the neighbourhood. While the preventive service network and the free curative care services provided by the government health facilities have been leading contributors to the country’s achievement in improvement of the health outcomes, the well organised training system has played a significant role in supplying health workers capable of providing a high standard of healthcare services. Nevertheless, there is still room for further improvement of the quality of the training services provided by Training Institutions for health workers.

The National Guidelines for Improvement of Quality and Safety of Healthcare Institutions provide a comprehensive set of quality standards and affordable measures to improve the training services provided by the Training Institutions for health workers. They are therefore expected to be fully oriented on these Guidelines and prepared to improve their working environment and process, as well as the training service delivery. Needless to say, the strong commitment of heads of institutions is critical in achieving the goals aimed by these Guidelines.

I wish to thank all the stakeholders involved in the development of this document as well as Japan International Cooperation Agency (JICA) for its technical assistance. In particular, I am grateful to Dr. Wimal Jayantha, DDG/Planning, who supervised the whole developmental process, Dr. S. Sridharan, Director OD, who led and facilitated the drafting work, Dr. C. J. Aluthweera, Coordinator for National Quality Assurance Programme, who provided technical inputs in development of the quality standards, and Mr. Shogo Kanamori, JICA Expert on Medical Services Administration, who provided coordinative and technical assistance.

Dr. Ravindra Ruberu Secretary Ministry of Health

20 October 2010

List of Contributors

Dr. Aluthweera, Champa; Coordinator for National Quality Assurance Programme, Ministry of Health

Mrs. Denipitiya, J.S.S.G.; Nursing Tutor, School of Nursing, Kandana

Mr. Dissanayake, Chaturanga; Project Assistant, JICA Advisor’s Office

Dr. Gamage, Rehan; Research Assistant, JICA Advisor’s Office

Dr. Jayantha, Wimal; DDG (Planning), Ministry of Health

Mr. Jayawardhane, P.L.; Principal, School of MLT – MRI, Colombo

Mrs. Jayawardhane, P.L.; Principal, School of Nursing, Kandana

Mrs. Kalahearachchi, S.; Principal, School of Nursing, Sri Jayawardhanepura

Mr. Kanamori, Shogo; JICA Expert on Medical Services Administration

Mrs. Nissanka, A.D.N.M.; Nursing Tutor, School of Nursing, Colombo

Mrs. Peiris, M.H.C.; Nursing Tutor, School of Nursing, Colombo

Dr. Piyaseeli, U.K.D.; Director, National Institute of Health Sciences, Ministry of Health

Mrs. Samaranayake, S.C.A.N.; Principal, School of Physiotherapist and Occupational Therapists, Colombo

Mrs. Siriwardhane, S.; Nursing Tutor, School of Nursing, Sri Jayawardhanepura

Dr. Sridharan, S.; Director Organization Development, Ministry of Health

Dr. Tissera, W.A.A.; Director Training, Ministry of Health

Dr. Wedamulla, Asanka; MO Planning, MDPU, Ministry of Health

TABLE OF CONTENTS

1. Introduction ……………………………………………………………………………….. 1

2. Quality Standards of Training Institutions ……………….……....………………….. 2

I. Working Environment (5S) ………………………………….………………….…. 3 1. Seiri (Sorting)

2. Seiton (Organisation) 3. Seiso (Cleaning with Meaning and for Beautifying) 4. Seiketsu (Standardisation) 5. Shitsuke (Training & Self-Discipline)

II. Overall Management of the Institution ……………………………………..……. 9 6. Leadership quality

7. Training system and performance 8. Human resource management 9. Record keeping 10. Waste management 11. Office management 12. Financial management 13. Responsiveness 14. Productivity and quality improvement programme 15. Public relations and community mobilisation

ANNEXES ……………………………………………………………………………………….. 14 ANNEX 1: Isles for Stationeries ………………………………………………………….. 14 ANNEX 2: Cleaning Checklist (Sample) …...……………………………………………. 15 ANNEX 3: Standardised Colour Codes ………………………………………………….. 16

APPENDIX: General Circular on National Quality Assurance Programme in Health 19

1. Introduction

These Guidelines will provide guidance to those working at Training Institutions for health workers in strengthening the organisational and individual preparedness for improvement of the quality and safety of the training institutions. It is assumed that these Guidelines will be used for the following purposes.

As a handbook for the staff at Training Institutions in implementing quality improvement programmes and related activities

As a guiding document for orientation programmes to the staff at Training Institutions conducted by the National Quality Secretariat of the Ministry of Health and the Provincial Quality Secretariats

The target institutions of these Guidelines include all the Training Institutions for health workers under the Ministry of Health and the Provincial Departments of Health Services.

Province District PDHS Line Ministry

Regional Training Centre

Nursing School Others

Western Province

1 Colombo 2

- Post Basic School of Nursing - MLT Training School - Medical Research Institute - Dental Therapist Training School – Maharagama - Radiography Training School – NHSL - Physiotherapy & Occupational Therapy Training School – NHSL - Pharmacist Training School – NHSL - ECG Technician Training School – NHSL - EEG Technician Training School – NHSL - Ophthalmic Technician Training School – Eye Hospital

2 Gampaha 1 3 Kalutara 1 - National Institute of Health Sciences

Central Province 4 Kandy 1 1 - MLT Training School - TH Peradenia 5 Nuwaraeliya 6 Matale

Southern Province

7 Galle 1 1 8 Matara 1 9 Hambantota 1

Northern Province

10 Jaffna 1 1 11 Kilinochchi 12 Mannar 13 Mullativu 14 Vavuniya

Eastern Province

15 Batticaloa 1 1 16 Ampara 1 17 Kalmunai 18 Trincomalee

North Western Province

19 Kurunegala 1 1 20 Puttalam

North Central Province

21 Anuradhapura 1 22 Polonnaruwa

Uva Province 23 Badulla 1 24 Monaragala

Sabaragamuwa Province

25 Kegalle 1 26 Ratnapura 1

Total 5 16 11

1

2. Quality Standards of Training Institutions

This chapter provides the quality standards of the Training Institutions for health workers. They are divided into two aspects and 15 areas.

I. Internal and External Customer Environment (5S) 1. Seiri (Sorting) 2. Seiton (Organisation) 3. Seiso (Cleaning with Meaning and for Beautifying) 4. Seiketsu (Standardisation) 5. Shitsuke (Training & Self-Discipline)

II. Overall Management of the Institution 6. Leadership quality 7. Training system and performance 8. Human resource management 9. Record keeping 10. Waste management 11. Office management 12. Financial management 13. Responsiveness 14. Productivity and quality improvement programme 15. Public relations and community mobilisation

These standards will be referred to whenever a Training Institution conducts quality improvement activities. They are also in line with the criteria for external audits and for selection of the National Health Excellency Award recipients.

2

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

1 Se

iri (S

ortin

g)

Elim

inat

ing

unne

cess

ary

item

s fro

m th

e w

orkp

lace

that

are

not

nee

ded

for c

urre

nt p

roce

ss a

t wor

k

1.1

Outsi

de an

d ins

ide pr

emise

s 1.1

.1 Un

wante

d item

s rem

oved

fro

m the

wor

kplac

e -

An es

tablis

hed p

roce

ss in

sortin

g wan

ted an

d unw

anted

items

is pr

esen

t. -

A pr

oper

proc

ess f

or co

ndem

ning i

tems i

s pre

sent.

-

Unwa

nted i

tems a

re no

t left i

n the

wor

kplac

e or m

arke

d with

tags

.

Red t

ags f

or th

ose i

tems t

o be d

ispos

ed

Or

ange

tags

for t

hose

items

unde

r con

sider

ation

. -

Tops

and i

nside

s of a

ll cup

boar

ds, s

helve

s, tab

les an

d dra

wers

are f

ree o

f unw

anted

/irre

levan

t ite

ms.

1.1.2

The f

loors

and p

assa

gewa

ys

in the

publi

c are

as eq

uippe

d wi

th ga

rbag

e bins

for g

ener

al wa

ste an

d kep

t free

of lit

ters

- Ga

rbag

e bins

for g

ener

al wa

ste ar

e in p

lace a

nd co

lour c

oded

. -

The t

ime f

or re

movin

g litte

rs fro

m the

garb

age b

ins ar

e ind

icated

. -

The p

lace i

s fre

e of li

tter.

1.1.3

Unwa

nted t

rees

and b

ranc

hes

remo

ved

(if ap

plica

ble)

- Tr

ees w

hich a

re ob

struc

ting t

he dr

ainag

e are

remo

ved.

- Tr

ee br

anch

es ab

ove t

he ro

of an

d ove

r the

elec

tric an

d tele

phon

e wire

s are

trim

med.

1.2

Wall

s and

notic

e bo

ards

1.2

.1 W

alls b

eing f

ree o

f old

poste

rs, pi

cture

s or c

alend

ars.

- Po

sters/

pictur

es ar

e not

fading

or to

rn.

- Inf

orma

tion o

n pos

ters/p

ictur

es is

not o

bsole

te.

- Ca

lenda

rs ar

e upd

ated.

1.2.2

Notic

e boa

rds b

eing f

ree o

f ob

solet

e noti

ces

- Re

mova

l instr

uctio

ns ar

e in p

lace.

- Th

e rem

oval

instru

ction

is co

mplie

d. -

Notic

e boa

rds a

re ca

tegor

ized a

ccor

ding t

o the

need

s. -

Resp

onsib

le pe

rsons

for e

ach n

otice

boar

d are

iden

tified

. -

The a

lignm

ent a

nd an

X-Y

axis

tool a

re m

aintai

ned i

n the

notic

e boa

rd.

3

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

2 Se

iton

(Org

anis

atio

n)

Ens

urin

g al

l the

item

s th

at h

ave

been

sor

ted

are

arra

nged

and

pla

ced

in p

re-a

ssig

ned

posi

tions

in o

rder

to fa

cilit

ate

effic

ienc

y at

wor

k.

2.1

Identi

ficati

on of

the

insti

tution

2.1

.1 A

name

boar

d of th

e ins

titutio

n and

a sit

e map

av

ailab

le

- A

name

boar

d of th

e ins

titutio

n is d

isplay

ed ou

tside

in al

l thre

e lan

guag

es.

- A

site m

ap is

disp

layed

at th

e entr

ance

/ rec

eptio

n are

a in a

ll thr

ee la

ngua

ges.

2.2

Dire

ction

al ind

icatio

ns

2.2.1

Dire

ction

al bo

ards

avail

able

at ev

ery j

uncti

on

- Di

recti

onal

boar

ds ar

e disp

layed

at ev

ery j

uncti

on ou

tside

and i

nside

of th

e ins

titutio

n to a

ll fac

ilities

fro

m the

entra

nce i

n all t

hree

lang

uage

s. 2.2

.2 Co

rrido

rs cle

arly

marke

d with

en

tranc

es an

d exit

lines

, cu

rved d

oor o

penin

gs, a

nd

direc

tion o

f trav

el

- Cu

rved d

oor o

penin

gs ar

e mar

ked a

t entr

ance

door

s to r

ooms

. -

The d

irecti

on of

trav

el is

indica

ted on

the c

orrid

ors.

- Th

e slid

ing do

ors a

re pr

ovide

d with

dire

ction

al ar

rows

.

2.3

Labe

lling a

nd

marki

ng

2.3.1

Room

s and

toile

ts cle

arly

identi

fied w

ith la

bels

- Al

l room

s and

toile

ts ar

e ide

ntifie

d with

labe

ls, na

me bo

ards

or nu

mber

s.

2.3.2

Stor

es an

d stor

age a

reas

pr

oper

ly or

ganis

ed

- Ite

ms in

stor

es an

d stor

age a

reas

are k

ept in

shelv

es, r

acks

or bi

ns an

d clea

rly m

arke

d. -

Shelf

grids

are m

arke

d with

refer

ence

numb

ers/n

ames

for e

asy r

etriev

al of

items

. -

All s

tation

eries

in th

e cup

boar

d are

kept

in pla

ces i

denti

fied w

ith sy

mbols

and m

arks

(visu

al co

ntrol

of sta

tione

ries).

-

Items

are s

tored

in an

alph

abeti

cal o

rder

and i

n a lo

gical

mann

er (le

ft to r

ight /

top to

botto

m).

- A

mech

anism

to re

plenis

h item

s is o

rgan

ized w

ith co

lour c

odes

:

Maxim

um st

ock l

evel:

Gre

en

Re

orde

r stoc

k lev

el: O

rang

e Mi

nimum

stoc

k lev

el: R

ed

2.3.3

Switc

hes a

nd fa

ns ea

sily

identi

fied

- Al

l swi

tches

and f

an re

gulat

ors a

re la

belle

d acc

ordin

gly.

- A

sepa

rate

electr

ical p

oint p

lan is

in pl

ace f

or ea

ch ro

om at

entra

nce.

2.4

Plac

ing an

d pa

rking

rules

2.4

.1 Eq

uipme

nt an

d too

ls be

ing

kept

in or

igina

l plac

es af

ter

use

- ‘Is

les’ a

re id

entifi

ed fo

r eac

h equ

ipmen

t and

tool

to be

kept

after

use w

ith th

e stra

ight li

ne m

ethod

and

shad

ow dr

awing

s disp

layed

. -

A me

chan

ism to

iden

tify pe

rsons

remo

ving i

tems f

rom

‘isles

’ Item

s is i

n plac

e.

An ex

ampl

e of ‘

Isles

’ is sh

own

in “A

NNEX

1: Is

les fo

r Sta

tione

ries”

.

4

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

2.4

.2 Fil

es an

d fold

ers a

rrang

ed

using

the m

istak

e pro

ofing

co

ncep

t

- Fil

es an

d box

folde

rs ar

e arra

nged

using

the m

istak

e pro

ofing

conc

ept to

facil

itate

identi

ficati

on of

pa

rticula

r file

s (wi

thin 3

0 sec

onds

) and

stor

ing in

origi

nal p

laces

.

2.4.3

Table

s and

chair

s plac

ed in

or

der

- Ta

bles a

nd ch

airs i

n the

offic

e are

arra

nged

acco

rding

to X

Y ax

is.

2.4.4

Parki

ng ar

eas f

or ve

hicles

sp

ecifie

d and

mar

ked

(If ap

plica

ble)

- Pa

rking

area

s for

vehic

les ar

e spe

cified

and m

arke

d. -

Vehic

le flo

ws ar

e ide

ntifie

d and

mar

ked.

-Si

gn bo

ards

for v

ehicl

es of

disa

bled p

erso

ns ar

e in p

lace.

3 Se

iso

(Cle

anin

g w

ith M

eani

ng a

nd fo

r Bea

utify

ing)

Cle

anin

g up

one

’s w

orkp

lace

com

plet

ely

to e

limin

ate

dust

on

floor

s, m

achi

nes

or e

quip

men

t.

3.1

Gene

ral

appe

aran

ce of

cle

anlin

ess

3.1.1

The p

remi

ses m

aintai

ned w

ith

healt

hy an

d safe

envir

onme

nt (if

appli

cable

)

- Th

e gar

den i

s pro

perly

main

taine

d and

land

scap

ing is

done

by a

gard

ener

. -

Drain

s are

not le

aking

or ov

erflo

wing

. -

Stag

natio

n of w

ater is

avoid

ed in

all d

rains

. -

The v

isible

parts

of th

e roo

f are

free

of un

wante

d item

s. -

The p

remi

ses a

re fe

e of:

Fli

es

Mo

squit

o bre

eding

sites

Stra

y dog

s and

cows

Cobw

ebs

3.1.2

Floor

s, wa

lls, w

indow

s and

cu

rtain

& oth

er fit

tings

being

ke

pt cle

an

- Th

e clea

nline

ss is

main

taine

d at:

Flo

ors

W

alls

W

indow

s

Curta

ins

Ot

her f

itting

s

Gu

tters

-A

clean

ing ch

eckli

st is

avail

able

and u

pdate

d.

5

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

3.1

.3 To

ilets

are c

lean a

nd in

wo

rking

orde

r -

Unple

asan

t odo

ur is

not e

xper

ience

d in t

oilets

. -

Toile

t facil

ities a

re ke

pt re

ady f

or us

e. -

A cle

aning

chec

klist

is av

ailab

le an

d upd

ated.

-Ad

equa

te ve

ntilat

ion is

prov

ided i

n all t

he to

ilets.

3.2

Cl

eanin

g of

mach

ines,

equip

ment,

tools

an

d fur

nitur

e

3.2.1

The c

leanli

ness

of bu

ilding

s, ma

chine

s, eq

uipme

nt, to

ols

and f

urnit

ure m

aintai

ned

- Th

e high

leve

l of c

leanli

ness

is m

aintai

ned w

ith no

visib

le dir

t:

Build

ings

Of

fice v

ehicl

es

Of

fice e

quipm

ent

Furn

iture

(tab

les, d

esks

, cha

irs, e

tc.)

3.3

Clea

ning p

racti

ce

3.3.1

An or

ganis

ed cl

eanin

g sys

tem

in pla

ce

- Th

e foll

owing

tools

and d

ocum

ents

are d

isplay

ed/av

ailab

le:

Cl

eanin

g res

pons

ibility

char

t

Clea

ning s

ched

ules

Cl

eanin

g guid

eline

s -

The a

bove

tools

and d

ocum

ents

are u

pdate

d mon

thly.

3.3.2

Clea

ning t

ools

and d

eterg

ents

prop

erly

store

d -

Prop

er st

orag

e fac

ilities

for c

leanin

g too

ls an

d dete

rgen

ts ar

e ava

ilable

. -

Clea

ning t

ools

for ou

tside

area

s/toil

ets an

d ins

ide ar

eas a

re se

para

ted.

3.3.3

An up

dated

clea

ning c

heck

list

avail

able

- A

clean

ing ch

eckli

st is

displa

yed a

nd m

ade v

isible

to th

e staf

f mem

bers.

-

Resp

onsib

le pe

rsonn

el for

clea

ning i

s ide

ntifie

d and

men

tione

d in t

he cl

eanin

g che

cklis

t. -

The c

leanin

g che

cklis

t is up

dated

wee

kly.

A sa

mpl

e clea

ning

chec

klist

is p

rovid

ed in

“ANN

EX 2:

Clea

ning

Che

cklis

t (Sa

mpl

e)”.

6

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

4 Se

iket

su (S

tand

ardi

zatio

n)

Gen

erat

ing

mec

hani

sms

to m

aint

ain

the

thre

e S

s (S

eiri,

Sei

ton

and

Sei

so) b

y de

velo

ping

pro

cedu

res,

sch

edul

es a

nd to

ols

for c

ontin

uous

ass

essm

ent a

nd

regu

lar a

udit.

4.1

Stan

dard

ized

visua

ls

4.1.1

Sign

boar

ds an

d dire

ction

al bo

ards

stan

dard

ised

- Al

l sign

boar

ds an

d dire

ction

al bo

ards

are s

tanda

rdise

d with

prop

er al

ignme

nt an

d con

sisten

t fonts

, an

d by c

olour

code

s. 4.1

.2 Ide

ntific

ation

labe

ls pla

ced o

n all

mac

hines

and e

quipm

ent

- Al

l mac

hines

and e

quipm

ent h

ave i

denti

ficati

on la

bels

with

the fo

llowi

ng in

forma

tion:

Na

me of

the i

tems

Ide

ntific

ation

and b

atch n

umbe

rs

Date

of ac

quisi

tion

Co

ntact

detai

ls of

maint

enan

ce co

mpan

y

Resp

onsib

le pe

rson f

or m

ainten

ance

Cost

of eq

uipme

nt 4.1

.3 Ca

ution

sign

s disp

layed

at

appr

opria

te pla

ces

- “D

ange

r” sig

ns ar

e disp

layed

at el

ectric

switc

hboa

rds a

nd tr

ansfo

rmer

s. -

“Slop

es” s

ings a

re di

splay

ed at

whe

reve

r the

re is

a slo

pe.

-“S

lippe

ry” si

gns w

ith ze

bra c

ode a

re pl

aced

at w

et flo

or af

ter cl

eanin

g. 4.1

.4 Op

en an

d shu

t dire

ction

al lab

els av

ailab

le on

door

s -

The d

irecti

onal

labels

are p

ut on

door

hand

les of

cupb

oard

s.

4.1.5

Was

te bin

s sep

arate

d, lab

elled

and c

olour

-code

d -

All th

e was

te bin

s are

sepa

rated

, labe

lled a

nd co

lour-c

oded

.

The c

olou

r-cod

es ar

e elab

orat

ed in

“ANN

EX 3:

Sta

ndar

dise

d Co

lour

Cod

es”

4.2

Maint

enan

ce of

ve

hicles

and

equip

ment

4.2.1

Vehic

les an

d equ

ipmen

t pr

oper

ly ma

intain

ed

- Ma

inten

ance

sche

dules

and r

ecor

ds ar

e ava

ilable

and u

pdate

d for

the f

ollow

ing ite

ms:

Ve

hicles

Offic

e equ

ipmen

t -

Oper

ation

al ins

tructi

ons a

re m

ade a

vaila

ble fo

r equ

ipmen

t. 4.3

Sa

fety a

nd

secu

rity

meas

ures

4.3.1

Secu

rity m

easu

res i

n plac

e for

a f

ire ev

ent

- Fu

nctio

nal fi

re ex

tingu

isher

s or s

and b

ucke

ts ar

e ava

ilable

. -

The g

uideli

nes o

r a pr

otoco

l for t

he fir

e eve

nt is

avail

able.

4.3

.2 Lig

htning

prote

ction

syste

m in

place

-

A lig

htning

prote

ction

syste

m is

in pla

ce.

7

I. In

tern

al a

nd E

xter

nal C

usto

mer

Env

ironm

ent (

5S)

Area

of C

once

rn

Stan

dard

s Me

asur

able

Elem

ents

5 Sh

itsuk

e (T

rain

ing

& S

elf-D

isci

plin

e)

Wor

king

on

5S a

s da

ily ro

utin

es a

nd e

nsur

ing

that

it b

ecom

es a

n in

tegr

al p

art o

f the

wor

kpla

ce fa

bric

.

5.1

Inter

nal a

udit

5.1.1

Inter

nal a

udits

on th

e qua

lity

and s

afety

impr

ovem

ent

cond

ucted

with

the c

heck

list

- An

inter

nal a

udit s

heet

on th

e qua

lity im

prov

emen

t of th

e ins

titutio

n is a

vaila

ble.

- A

team

has b

een a

ppoin

ted to

cond

uct th

e inte

rnal

audit

. -

The i

ntern

al au

dit is

cond

ucted

at le

ast o

nce i

n thr

ee m

onths

. 5.2

Tr

aining

and

raisi

ng

awar

enes

s

5.2.1

The s

taff tr

ained

on 5S

, pr

oduc

tivity

and q

uality

-

All th

e staf

f are

train

ed on

5S, p

rodu

ctivit

y and

quali

ty.

- A

prog

ramm

e to t

rain

new

staff o

n 5S,

prod

uctiv

ity an

d qua

lity is

avail

able.

5.2

.2 A

syste

m to

give a

ward

s to

well-p

erfor

med s

taff a

nd un

its

avail

able

- An

even

t to ap

prec

iate b

est p

erfor

ming

emplo

yees

is ca

rried

out a

nnua

lly.

8

II.

Ove

rall

Man

agem

ent o

f the

Inst

itutio

n Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

6 Le

ader

ship

qua

lity

6.1

Lead

ersh

ip qu

ality

6.1.1

Visio

n, Mi

ssion

and v

alues

of

the in

stitut

ion av

ailab

le -

The V

ision

, Miss

ion an

d valu

es of

the i

nstitu

tion a

re di

splay

ed in

a vis

ible p

lace.

- Th

e staf

f are

awar

e of th

e Visi

on, M

ission

and v

alues

, and

unde

rstan

d the

m.

6.1.2

Prod

uctiv

ity ba

sed g

oals

and

objec

tives

avail

able

- Pr

oduc

tivity

base

d goa

ls an

d obje

ctive

s of th

e ins

titutio

n are

avail

able.

6.1.3

The m

anag

emen

t of th

e ins

titutio

n bas

ed on

plan

s -

The f

ollow

ing pl

ans a

re de

velop

ed an

d ava

ilable

.

Train

ing ca

lenda

r (an

nual)

Timeta

ble (m

onthl

y/wee

kly)

An

nual

plan o

f the i

nstitu

tion

Mediu

m-ter

m pla

n of th

e ins

titutio

n

7 Tr

aini

ng s

yste

m a

nd p

erfo

rman

ce

7.1

Train

ing

perfo

rman

ce

7.1.1

Train

ing pr

ogra

mmes

co

nduc

ted ac

cord

ing to

the

plan

- Tr

aining

prog

ramm

es ar

e con

ducte

d acc

ordin

g to t

he an

nual

traini

ng ca

lenda

r.

7.1.2

The p

ass r

ates o

f the f

inal

exam

satis

factor

y -

The p

ass r

ate at

the f

inal e

xam

is hig

her t

han 8

0%.

7.2

Train

ing sy

stem

7.2.1

The t

raini

ng pr

ovide

d in a

n ap

prop

riate

mann

er

- Up

dated

curri

culum

and l

esso

n plan

s are

avail

able

for ea

ch tr

aining

sess

ion.

- Pr

e and

post

evalu

ation

is co

nduc

ted fo

r eac

h tra

ining

sess

ion.

- A

stude

nt co

unse

lling s

ystem

is in

plac

e. -

Extra

-curri

cular

and c

o-cu

rricu

lar ac

tivitie

s are

cond

ucted

. 7.2

.2 Tr

aining

facil

ities a

nd

equip

ment

appr

opria

te -

The r

ooms

for le

cture

sess

ions a

nd pr

actic

al se

ssion

s are

adeq

uate

for th

e tra

ining

. -

Adeq

uate

furnit

ure a

nd A

V eq

uipme

nt is

avail

able

for tr

aining

. -

A lib

rary

is av

ailab

le an

d fun

ction

al.

7.3

Perfo

rman

ce

revie

w 7.3

.1 A

functi

onal

supe

rviso

ry sy

stem

in pla

ce

- Th

e mon

thly m

eetin

g of th

e ins

titutio

n is c

ondu

cted a

nd m

inutes

are k

ept.

- A

supe

rviso

ry sta

ff cha

rt is

avail

able.

-

Regu

lar in

spec

tions

of th

e tra

ining

are c

ondu

cted b

y sup

ervis

ory s

taff.

-

Repo

rts on

supe

rviso

ry ins

pecti

ons a

re av

ailab

le an

d upd

ated.

9

II.

Ove

rall

Man

agem

ent o

f the

Inst

itutio

n Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

7.3

.2 Pe

rform

ance

comp

iled a

nd

revie

wed

- Qu

arter

ly me

eting

s to r

eview

the o

rgan

isatio

nal p

erfor

manc

e are

cond

ucted

and d

ocum

ented

. -

Month

ly re

ports

on tr

aining

activ

ities a

re co

mpile

d. -

Annu

al re

ports

on th

e per

forma

nce a

re co

mpile

d and

distr

ibuted

.

8 H

uman

reso

urce

man

agem

ent

8.1

Huma

n res

ource

ma

nage

ment

8.1.1

Staff

train

ing co

nduc

ted

regu

larly

- A

staff t

raini

ng an

nual

plan i

s ava

ilable

. -

A sta

ff tra

ining

reco

rd bo

ok is

avail

able

and u

pdate

d. -

A co

ordin

ator f

or st

aff tr

aining

is as

signe

d. 8.1

.2 St

aff de

ploym

ent a

dequ

ately

mana

ged

- Th

e cad

re an

d the

curre

nt sta

tus of

the s

taff a

re di

splay

ed an

d upd

ated.

- St

aff de

ploym

ent r

ecor

d boo

ks ar

e ava

ilable

for a

ll cate

gorie

s of s

taff a

nd up

dated

. -

Perso

nal fi

les ar

e ava

ilable

for e

ach s

taff a

nd up

dated

. 8.1

.3 Jo

b des

cripti

ons f

or al

l ca

tegor

ies of

staff

avail

able

- Jo

b des

cripti

ons f

or al

l cate

gorie

s of th

e sta

ff are

avail

able

and d

istrib

uted t

o the

staff

.

8.1.4

Appr

aisal

syste

m in

place

-

A sta

ff app

raisa

l form

at is

avail

able.

-

Staff

appr

aisal

is co

nduc

ted on

a re

gular

basis

. 8.1

.5 St

aff w

elfar

e sch

emes

av

ailab

le -

Staff

welf

are s

chem

es (e

.g. an

nual

functi

ons,

loan s

chem

es, e

tc.) a

re av

ailab

le.

9 R

ecor

d ke

epin

g

9.1

Reco

rd ke

eping

9.1

.1 Re

cord

s kep

t in an

orga

nized

ma

nner

-

Reco

rds a

re ke

pt in

a rec

ord r

oom

in an

orga

nized

man

ner.

- Th

e foll

owing

infor

matio

n is r

eadil

y ava

ilable

:

The n

umbe

r rec

ruite

d in a

batch

The n

umbe

r suc

cess

fully

comp

leted

in a

batch

Resu

lts of

stud

ents

- Sk

eletal

files

are m

aintai

ned f

or ea

ch st

uden

t. -

A da

tabas

e sys

tem is

avail

able

for be

tter m

anag

emen

t of r

ecor

ds.

10

II.

Ove

rall

Man

agem

ent o

f the

Inst

itutio

n Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

10

Was

te m

anag

emen

t

10.1

Was

te ma

nage

ment

10.1.

1 W

aste

prod

uced

durin

g pr

actic

al se

ssion

s ade

quate

ly dis

pose

d

- Fiv

e typ

es of

was

tes ar

e seg

rega

ted by

the c

olour

code

s:

Gene

ral w

astes

Shar

ps

Inf

ected

was

tes

Pl

astic

s

Glas

ses

- A

colou

r cod

ing ch

art fo

r the

was

te se

greg

ation

is di

splay

ed.

- Th

e was

te se

greg

ation

is or

ganis

ed at

the w

aste

dispo

sal a

rea a

ccor

ding t

o the

colou

r cod

es.

-An

incin

erato

r or a

prop

er m

echa

nism

for th

e fina

l disp

osal

of wa

stes i

s ava

ilable

and f

uncti

oning

. 10

.1.2

Haza

rdou

s was

tes di

spos

ed

prop

erly

- Di

spos

al bin

s for

shar

ps in

cludin

g nee

dles a

re in

plac

e acc

ordin

gly.

-A

proto

col fo

r disp

osal

of wa

ste bo

dy flu

id an

d bloo

d com

pone

nts ar

e ava

ilable

and a

dher

ed to

.

11 O

ffice

man

agem

ent

11.1

Offic

e ma

nage

ment

syste

m

11.1.

1 A

functi

onal

office

ma

nage

ment

syste

m in

place

-

The n

ame,

desig

natio

n and

the s

ubjec

t of e

very

healt

h man

agem

ent a

ssist

ant (

HMA)

is av

ailab

le at

the en

tranc

e of th

e offic

e. -

Name

and s

ubjec

t of e

ach H

MA is

disp

layed

on ea

ch H

MA’s

table.

-

All th

e file

s hav

e ide

ntific

ation

numb

ers a

nd do

cume

nts in

the f

iles a

re nu

mber

ed in

a sta

ndar

d ma

nner

. -

A me

chan

ism to

cove

r up a

bsen

ce of

offic

e staf

f is in

plac

e. -

An in

built

mech

anism

to re

ceive

and s

end l

etter

s and

faxe

s is i

n plac

e. 11

.2 Of

fice e

quipm

ent

and c

onsu

mable

s 11

.2.1

Offic

e equ

ipmen

t pro

perly

ma

nage

d -

An in

vento

ry of

the of

fice e

quipm

ent is

avail

able

and u

pdate

d. -

Each

equip

ment

has a

sepa

rate

file w

ith m

ainten

ance

reco

rds a

nd al

l the o

ther d

etails

. 11

.2.2

Offic

e con

suma

bles p

rope

rly

mana

ged

- An

nual

stock

requ

ireme

nt is

avail

able

for ea

ch co

nsum

able

item.

-

Supp

lier in

forma

tion o

f the o

ffice c

onsu

mable

s is a

vaila

ble.

- A

prop

er pr

oces

s to i

ssue

cons

umab

le ite

ms to

the u

nit on

requ

est is

in pl

ace.

12 F

inan

cial

man

agem

ent

12.1

Finan

cial

mana

geme

nt 12

.1.1

Salar

y she

ets/vo

uche

rs pr

oper

ly co

mplet

ed

- Th

e sala

ry sh

eets

and v

ouch

ers a

re co

mplet

ed pr

oper

ly.

11

II.

Ove

rall

Man

agem

ent o

f the

Inst

itutio

n Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

12

.1.2

Over

time/a

llowa

nce p

ayme

nt in

time

- Ov

ertim

e and

allow

ance

paym

ents

for st

aff ar

e don

e in t

ime.

12.1.

3 Ca

sh an

d acc

ounts

man

aged

pr

oper

ly -

The a

ctual

cash

balan

ce co

mplie

s with

the r

ecor

d in t

he ca

sh bo

ok.

- Th

e acc

ounts

are m

aintai

ned p

rope

rly.

-Th

e retu

rns o

f pett

y cas

h rele

ased

to th

e ins

titutio

ns ar

e coll

ected

in tim

e. 12

.1.4

Stoc

k ver

ificati

on co

nduc

ted

prop

erly

(if ap

plica

ble)

- St

ock v

erific

ation

is co

nduc

ted pr

oper

ly.

13 R

espo

nsiv

enes

s

13.1

Resp

onsiv

enes

s to

custo

mers

13.1.

1 Ad

equa

te fac

ilities

and

envir

onme

nt at

class

room

s an

d tra

ining

area

s

- Ad

equa

te lig

ht an

d ven

tilatio

n is a

vaila

ble at

clas

sroom

s and

train

ing ar

eas w

ith m

inimu

m ex

terna

l dis

turba

nces

. -

Adeq

uate

resid

entia

l facil

ities a

re av

ailab

le for

stud

ents.

-

Recre

ation

facil

ities a

re av

ailab

le for

stud

ents.

13

.1.2

Infor

matio

n ava

ilable

for

visito

rs -

A re

cepti

on de

sk is

avail

able

with

a tra

ined p

erso

n in c

harg

e. -

Esse

ntial

infor

matio

n is p

rovid

ed fo

r visi

tors.

-A

reso

urce

centr

e whic

h pro

vides

broc

hure

s, lea

flet a

nd ot

her m

ateria

ls is

avail

able

and f

uncti

oning

. 13

.1.3

Basic

facil

ities a

vaila

ble fo

r vis

itors

- Se

ating

facil

ities a

re av

ailab

le for

visit

ors.

-Ba

sic fa

cilitie

s inc

luding

drink

ing w

ater a

nd a

clean

usab

le toi

let ar

e ava

ilable

for v

isitor

s. 13

.1.4

Stud

ents

prov

ided w

ith

healt

hcar

e ser

vices

and

prev

entiv

e mea

sure

s

- St

uden

ts ar

e vac

cinate

d aga

inst H

epati

tis B

. -

Stud

ents

are p

rovid

ed w

ith he

alth s

creen

ing.

- A

first a

id ce

ntre i

s ava

ilable

and f

uncti

oning

. 13

.1.5

Publi

c and

stud

ent c

ompla

ints

are h

andle

d pro

perly

-

A re

gister

for p

ublic

and s

tuden

t com

plaint

s and

actio

ns ta

ken i

s ava

ilable

and m

aintai

ned.

13.2

Resp

onsiv

enes

s to

staff m

embe

rs 13

.2.1

Staff

mem

bers

prov

ided w

ith

healt

h scre

ening

and o

ther

prev

entiv

e car

e ser

vices

- St

aff m

embe

rs ar

e pro

vided

with

healt

h scre

ening

annu

ally.

- He

alth r

ecor

ds of

all th

e staf

f mem

bers

are a

vaila

ble.

-Te

achin

g staf

f con

ducti

ng pr

actic

al se

ssion

s are

prov

ided w

ith H

epati

tis B

immu

nizati

on.

13.2.

2 St

aff su

gges

tions

hand

led

prop

erly

- A

mech

anism

to re

ceive

and r

eview

staff

sugg

estio

ns is

in pl

ace.

12

II.

Ove

rall

Man

agem

ent o

f the

Inst

itutio

n Ar

eas o

f Con

cern

St

anda

rds

Me

asur

able

Elem

ents

13

.3 Re

spon

siven

ess

to sp

ecial

ised

grou

ps

13.3.

1 Se

cure

acce

ss pr

ovide

d for

the

disa

bled p

erso

ns an

d se

nior c

itizen

s.

- Sp

ecial

acce

ss at

stair

ways

is av

ailab

le for

the d

isable

d per

sons

and s

enior

citiz

ens.

14

Prod

uctiv

ity a

nd q

ualit

y im

prov

emen

t pro

gram

me

14.1

Prod

uctiv

ity an

d qu

ality

impr

ovem

ent

prog

ramm

e

14.1.

1 Qu

ality

impr

ovem

ent s

ystem

in

place

-

Quali

ty cir

cles o

r wor

k imp

rove

ment

teams

are e

stabli

shed

and f

uncti

onal.

-

Prod

uctiv

ity an

d qua

lity im

prov

emen

t pro

gram

mes s

uch a

s 5S

imple

menta

tion a

t the i

nstitu

tion a

re

cond

ucted

regu

larly

and d

ocum

ented

. 14

.1.2

Senio

r man

ager

s inv

olved

in

quali

ty im

prov

emen

t acti

vities

-

Senio

r man

ager

s init

iate a

nd at

tend m

eetin

gs to

imple

ment

quali

ty ma

nage

ment

activ

ities.

-Re

cord

s ind

icatin

g the

partic

ipatio

n of th

e sen

ior m

anag

ers i

n the

abov

e acti

vities

are a

vaila

ble.

14.1.

3 St

uden

t and

teac

her

evalu

ation

syste

m in

place

-

The s

ystem

to ev

aluate

teac

hing s

taff b

y stud

ents

is in

place

. -

A me

chan

ism to

refle

ct the

evalu

ation

resu

lts to

the t

raini

ng se

rvice

s is i

n plac

e. 14

.1.4

-

15

Publ

ic re

latio

ns a

nd c

omm

unity

mob

ilisa

tion

15.1

Publi

c rela

tions

an

d com

munit

y mo

bilisa

tion

15.1.

1 Co

mmun

ity pa

rticipa

tion

mech

anism

in pl

ace

- A

mech

anism

to ha

ndle

dona

tions

and o

ther a

ssist

ance

from

the c

ommu

nity i

s org

anise

d.

15.1.

2 Co

mmen

datio

n fro

m the

pu

blic r

eceiv

ed

- Co

mmen

datio

n fro

m the

publi

c are

reco

rded

. -

A me

chan

ism to

diss

emina

te co

mmen

datio

ns fr

om th

e pub

lic to

the s

taff m

embe

rs is

in pla

ce.

13

AN

NEX

1: I

sles

for S

tatio

nerie

s

Sh

adow

dra

win

g

14

ANNEX 2: Cleaning Checklist (Sample)

Cleaning Checklist (Sample)

Month/Year: September 2010

Item Responsible Person Time Week I II III IV

Fans Mr. Fernando Sat. 3.00pm X

Carpet Mrs. Perera Sun. 10.00am X

15

AN

NEX

3: S

tand

ardi

sed

Col

our C

odes

(Info

rmat

ion

prov

ided

by

cour

tesy

of C

astle

Stre

et H

ospi

tal f

or W

omen

)

Stan

dard

ised

Col

our C

odes

Red

:

Un-

ster

ile

Em

pty

N

egat

ive

Blu

e:

Ster

ile

Fu

ll

Posi

tive

Gre

en:

Saf

e

Qua

lity

& S

afet

y

Yello

w:

Infe

ctio

n

Bla

ck:

Gen

eral

16

APPENDIX

17

APPENDIX: General Circular on National Quality Assurance Programme in Health

18


General Circular Letter No. 01-29/ 2009 My No. HPI/ OD/ 06/ 2009. Ministry of Healthcare & Nutrition

“Suwasiripaya”, 385, Rev. Baddegama Wimalawansa Thero Mawatha, Colombo 10. 22, September 2009.

To : Addl. Secretaries All Provincial Secretaries of Health, Director General of Health Services, All Deputy Director Generals and Directors, All Provincial Directors of Health Services, All Regional Directors of Health Services, and All Heads of Health Institutions.

National Quality Assurance Programme in Health We are pleased to note that some of our hospitals and other health institutions have initiated

productivity and quality improvement programmes as per instruction given by the General

Circular No 02-109/2003 and dated 08th October 2003.

The Ministry of Healthcare and Nutrition has decided to expand the Quality Assurance

Programme to all health institutions in Sri Lanka, in order to improve the quality and safety of

health care services. It aims at establishing a continuous quality improvement process by setting up

organizational structures and mechanisms at all health care institutions.

1. Quality Secretariat (QS)

Ministry of Healthcare & Nutrition has established a Quality Secretariat (QS) to direct

management of the Quality Assurance Programme.

2. Quality Management Units (QMU)

All health institutions should establish a Quality Management Unit (QMU) to create quality

and safety culture towards improving Quality of Healthcare. This unit will undertake planning

the implementation and monitoring of the National Quality Assurance Programme with the

19


guidance of the Quality Secretariat, Ministry of Healthcare & Nutrition. Please see the

Organizational Structure in annexure.

3. Roles and Functions

I. Quality Secretariat

i. To facilitate the implementation of national policies related to quality and safety.

ii. Prepare and disseminate standards, guidelines and procedures.

iii. Development of training packages in order to strengthen capacity building of staff.

iv. Coordination with relevant health and health related sectors for quality assessment and

improvement.

v. Facilitate the development of a shared learning environment and continued achievement

of best practices.

vi. Develop and implement a continuous monitoring & evaluation system.

vii. Mobilize resources for the continuous improvement of quality and safety in the health

system.

viii. To facilitate the development of the legal and regulatory framework for the

implementation of quality and safety policy.

II. Quality Management Unit (QMU)

i. Quality Management Units (QMU) will be established in National Hospital of Sri Lanka,

Teaching Hospitals, Provincial General Hospitals, District General Hospitals and Base

Hospitals and specialised hospitals.

ii. All campaigns, decentralized units and special units under the Ministry of Healthcare &

Nutrition are expected to establish Quality Management Unit.

iii. Divisional Hospitals (District Hospitals, Peripheral Units and Rural Hospitals), and

Primary Medical Care Units (Central Dispensary & Maternity Home and Central

Dispensary) are expected to conduct their Quality Management Programme under a

designated officer who will be guided by the Quality Management Unit of RDHS.

iv. All MOOH are expected to plan and implement the Quality Management Programme,

under the guidance of the Quality Management Unit of RDHS.

20


v. To facilitate development of a shared learning environment and continued achievement

of best practices.

III. Functions of QMU

QMU would coordinate the quality assurance and client safety program of the healthcare institutions through following functions.

i. Promote employee participation in management of quality by establishing Work Improvement

Teams (WIT) /Quality Circles (QC) in for the different departments/units within the health

institution.

ii. Conduct training of Work Improvement Teams (WIT).

iii. Maintain a database in staff training and conduct a planned In-service Training Programme.

iv. Conduct programs and workshops on quality improvement and patient safety focussing on

problem solving approaches and measurements.

v. Initiate a quality culture in health institutions by introducing 5S concepts leading towards Total

Quality Improvement (TQI).

vi. Ensure management leadership and involvement of medical consultants in the quality

improvement process.

vii. Assist in preparing strategic plans for the institutions with focus on reduction of waiting times,

instituting a smooth patient flow, infection control and waste disposal.

viii. Implementation of standards, guidelines and protocols relevant to customer/ patient care

including clinical pathways.

ix. Maintain a computer based data system by collecting and analysing data related to quality

improvement of services (eg. Patient accidents and adverse events, near misses re-admissions,

case fatality rates, complication arising from medical and surgical procedures, referrals, adverse

events following immunization and transfers, etc).

x. Prepare and distribute half yearly / quarterly bulletins and annual performance reports with

the assistance of Medical Record Unit (MRU) and other relevant units.

xi. Promote an environment friendly healthcare institution.

xii. Conduct customer satisfaction surveys, and employee satisfaction surveys, maintain and take

corrective action for public complaints. Encourage suggestion scheme in healthcare

institutions.

21


xiii. Ensure quality of supplies by encouraging maintenance contract agreements for support

services in order to impalement Total Productivity Maintenance of the supplies.

xiv. Develop Annual Procurement plans for different variety of purchases.

xv. Organize and update supplier and maintenance information system and disseminate to the

relevant Units.

xvi. Facilitate assessment and improvement of performance through regular monitoring of the

programme using quality measurement indicators (Guidelines will be sent).

xvii. Assist and conduct performance reviews and maintain records of such reviews.

xviii. Promote studies, research and medical audits in the institutions.

xix. Assist Non Health Sectors to implement Productivity and Quality Assurance Programmes.

Contact Details

Quality Secretariat is located at;

Castle Street Hospital Complex, Colombo 08.

Tele: 011 2678598, 011 2678599, Fax 011 - 2695244

e- mail: Quality Secretariat" <[email protected]>. Dr. Athula Kahadaliyanage Dr. Ajith Mendis Secretary Director General of Health Service Ministry of Healthcare & Nutrition

22


Annexure

Organizational Structure

Quality Secretariat Ministry of Healthcare &

Nutrition

Quality Management Unit

TH & Other Special hospitals under MoH

Quality Management Unit All Campaigns & Specialized Units


PH, DGH, BH

Divisional Hospitals & Primary Medical Care

Units

MOH Office


PDHS (Planning Unit)

Quality Management Unit RDHS

(Planning Unit)

23


24

Feedback Form National Guidelines for Improvement of Quality and Safety of Healthcare Institutions

(For Training Institutions)

Kindly provide feedback for improvement of this document. We will try our best to incorporate your views and opinions into the next edition of these Guidelines.

Name: Title: Institution: Address: Tel: E-mail: Please write your suggestions for improvement of these Guidelines below:

Kindly mail this form to:

Director Organization Development, Ministry of Health, 385 Baddegama Wimalawansa Thero Mw., Colombo 10, Sri Lanka

national guidelines for€¦ · and mr. shogo kanamori, jica expert on medical services...

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